Gestational Diabetes (Diabetes During Pregnancy)

In short: Gestational diabetes is diabetes that appears during pregnancy when the body does not make enough insulin. It is usually tested for between weeks 24 and 28, earlier in women with risk factors. It is treated with a balanced diet and exercise, and insulin or tablets when needed. Blood sugar usually returns to normal within 6 weeks of delivery, but the risk of type 2 diabetes later remains.

Definition of Diabetes During Pregnancy:

Gestational diabetes is a type of diabetes that starts during pregnancy. When the pregnant woman has diabetes, her body is not able to consume the sugar (glucose) in her blood as well as it should. So the level of glucose in the blood becomes above normal. Gestational diabetes occurs in about 10-15% of pregnant women worldwide, and it is even more common in the Middle East. It is usually diagnosed in the fifth or sixth month of pregnancy (Between the 24th and 28th weeks). Gestational diabetes occurs because your body is unable to produce enough insulin, the hormone responsible for controlling blood sugar levels.

Generally, Females are cured from gestational diabetes after delivery.

Causes of gestational diabetes:

Almost all women have some degree of impaired glucose intolerance during pregnancy due to the hormonal changes that occur during pregnancy. In this case, the level of glucose in the blood may be higher than normal, but not high enough to cause diabetes. During the last phase of the pregnancy (the third trimester), these hormonal changes place pregnant women at risk for gestational diabetes.

During pregnancy, increased levels of certain hormones made in the placenta (the organ that connects the baby by the umbilical cord to the uterus) help shifting nutrients from the mother to the growing fetus. The placenta produces hormones to prevent developing low blood sugar. They stop the actions of insulin.

Over the course of the pregnancy, these hormones produce impaired glucose intolerance, which increase the level of glucose in the blood. In order to decrease this level, the body makes more insulin to shuttle glucose into cells.

Usually the mother’s pancreas can produce more insulin (about three times the normal amount) to overcome the effect of the pregnancy hormones on glucose levels. When the pancreas cannot produce enough insulin to do it, the glucose levels will raise and cause gestational diabetes.

Risk factors for Diabetes During Pregnancy:

• being overweight prior to becoming pregnant.
• Having glucose in the urine.
• Impaired glucose tolerance or impaired fasting glucose (blood-glucose glucose levels are high, but not high enough to be diabetic.)
• Family history of diabetes. (If the parents or siblings have diabetes)
• Previously giving birth to a baby over 9 pounds.
• Previously giving birth to a stillborn baby.
• Having gestational diabetes with a previous pregnancy.
• Increased Amniotic fluid Volume (A condition called polyhydramnios)
• The family origin is Chinese, South Asian, African Caribbean, or Middle Eastern.
• Many women may develop gestational diabetes without having any risk factors.

Symptoms of Diabetes During Pregnancy:

Usually, there are no symptoms, but the following may be occurred:

• Increased thirst
• Increased urination
• Weight loss in spite of increased appetite
• Fatigue
• Nausea and vomiting
• Frequent infections, including those of the bladder vagina and skin
• Blurred vision

Note. Although these symptoms are also common later in pregnancy anyway.

Diagnosis of Diabetes During Pregnancy:

High-risk females should be screened for gestational diabetes as early as possible during their pregnancies. All other women will be screened between the 24th and 28th week of pregnancy.

To test for gestational diabetes, the pregnant woman is usually given an “Oral Glucose Tolerance Test”. The 75 g OGTT: after fasting overnight (8-10 hours) a fasting blood sample is taken, she drinks 75 g of glucose, and blood is taken again after one and two hours. Gestational diabetes is diagnosed if fasting ≥92, 1 h ≥180 or 2 h ≥153 mg/dl. Some centres first use a 50 g one-hour screen; a result of 140 mg/dl or more means the full 75 g test is needed.

A high-risk woman whose early test is normal should have the test repeated between weeks 24 and 28 of pregnancy.

If the woman has a history of gestational diabetes in a previous pregnancy, she will be given a kit containing blood glucose monitoring devices at the beginning of the pregnancy. If the readings are normal, a gestational diabetes test will be performed between weeks 24 and 28 of pregnancy.

• Treatment of Diabetes During Pregnancy:

Monitoring is carried out by a team consisting of an obstetrician-gynecologist, an endocrinologist, and a neonatal specialist.

The aims of treatments are to maintain the blood-glucose level within the normal limits during the pregnancy, and ensure the well-being of the fetus. 1- Close monitoring of the mother and fetus should continue throughout the pregnancy.

• Fetal monitoring to assess the fetal size and well-being may include ultrasound exams and non-stress tests, a very simple and painless test,for both mother and fetus. An electronic fetal monitor (a machine that hears and displays the baby’s heartbeat) is placed on the abdomen. When the fetus moves, His heart rate normally increases 15 to 20 beats above its regular rate.
• Self-monitoring of blood-glucose level allows the women to participate in her care. Monitoring glucose levels in the blood four times per day (before breakfast and two hours after meals, monitoring blood glucose before all meals may also become necessary) the range included: before breakfast: below 95 mg/dl; one hour after meals: below 140 mg/dl; or two hours after meals: below 115-120 mg/dl

2- Following specific dietary guidelines as instructed by the dietician. The pregnant will be asked to distribute the calories evenly throughout the day. Following these eating tips:

• Eat three small meals and two or three snacks at the regular time’s every day. Try not to skip meals or snacks. Carbohydrates should be 40% - 45% of the total calories with breakfast and the bedtime snack should contain 15 – 30 grams of carbohydrates.
• If the mother complains of nausea and vomiting, she should eat 1-2 servings of crackers, cereal or pretzels before getting out of bed. Eat small, frequent meals throughout the day and avoid fatty, fried and greasy foods. If she takes insulin and has morning sickness, make sure how to treat hypoglycemia.
• Choose food high in fiber such as whole-grain breads cereals, pasta, rice, fruits and vegetables. All pregnant women should eat 20 – 35 grams of fiber a day.
• Fat should be less than 40% of calories with less than 10% consumed being from saturated fats.
• The pregnant woman should make sure that she is getting enough vitamins and minerals in her daily diet.
• Drink at least 8 cups or 64 ounces of liquids per day.

3- Regular exercise during pregnancy can improve the posture and decrease some common discomforts such as backache and fatigue. Being fit during pregnancy is important: aim for at least 150 minutes of moderate exercise a week (for example, a 30-minute brisk walk on most days, ideally after meals, which also helps lower blood sugar). However, every pregnant woman should consult with her doctor before beginning an exercise program.

Since both insulin and exercise lower blood glucose, the mother should follow additional exercise to avoid a low blood-glucose reaction:

• Always carry any kind of sugar with her when exercising such as glucose tablets or hard candy.
• Eat one serving of fruit or the equivalent of 15 g of carbohydrate for most activities lasting 30 min. If the pregnant woman exercises two hours or more after a meal, you should eat a snack before exercise

4- Monitoring weight gain: The recommend amount of weight gained during pregnancy depends on the pre-pregnancy weight. Typically, gain weight more during the second and third trimester and recommended intakes of calories should increase at that time.

5- If you gain the proper amount of weight during pregnancy by eating a healthy, balanced diet, then it is a good sign that the baby is getting all the nutriments he or she needs and is growing at a healthy rate.

6- It is not necessary to “eat for two” during pregnancy. It’s true that pregnant woman needs extra calories from nutrient-rich food to help her baby grow, but she generally needs to consume 200 to 300 more calories than she did before she became pregnant to meet the needs of her growing baby. She must ask the doctor how much weight she should gain during pregnancy. A female of average weight before pregnancy can expect to gain 25 to 35 pounds during pregnancy. She may need to gain more or less weight, depending on what her doctor recommends.

7- In general, a woman of normal weight should gain only about 1-4 pounds (0.5-2 kg) during the first three months of pregnancy and about 1 pound (0.4-0.5 kg) a week for the remainder of the pregnancy; women who are overweight should gain less.

The weight will be distributed as follows:

• Baby 8 pounds
• Placenta 2-3 pounds
• Amniotic fluid 2-3 pounds
• Breast tissue 2-3 pounds
• Blood supply 4 pounds
• Fat stores for delivery and breast-feeding 5-9 pounds
• Uterus increase 2-5 pounds

8- Medical Treatment:

• Based on the mother’s blood glucose monitoring results, the doctor will tell her if she needs to take insulin in the form of injections during pregnancy. Insulin is a hormone which controls blood glucose. If insulin is prescribed for her, she may be taught to perform the insulin injection procedure.

If diet and exercise do not bring blood sugar to target within 1-2 weeks, tablets (metformin) are often the first medicine offered, as they are safe in pregnancy and avoid injections. Insulin is used instead of, or together with, metformin if blood sugar remains high, if the fasting sugar is very high at diagnosis (126 mg/dl or more), or if the baby is growing too large.

• As the pregnancy progresses, the placenta will make more pregnancy hormones and larger doses of insulin may be needed to control the mother’s blood glucose. The doctor will adjust her insulin dosage based on her blood-glucose level.
• When using insulin, a “low blood-glucose reaction,” or hypoglycemia, can occur if the mother does not eat enough food, skip a meal, do not eat at the right time of day, or if she exercises more than usual.
• Symptoms of hypoglycemia include:
• Confusion
• Dizziness
• feeling shaky
• Head aches
• Sudden hunger
• sweating
• Weakness

Hypoglycemia is a serious problem that needs to be treated right away. If the pregnant woman thinks that she has a low blood-glucose reaction, she should check her blood glucose. If the blood glucose is less than 70 mg/dl, eat food containing sugar, such as 1/2 cup of orange or apple juice, 1 cup of skim milk, 4-6 pieces of a hard candy (not sugar – free), 1/2 cup regular soft drink; or 1 tbsp of honey, brown sugar or corn syrup. 15 min after eating one of the food listed above, check your blood sugar again. If it is still less than 70 mg/dl, eat another one of the food choices above. If it is more than 45 min until the next meal, eat a bread and protein source to prevent another reaction. Record all low blood-glucose reactions in the logbook, including the date, time of day the reaction occurred and how she treated it.

Complications of Diabetes During Pregnancy:

Diabetes in pregnancy affects the developing baby throughout the pregnancy. Note that the early-pregnancy risks below (birth defects and miscarriage) apply mainly to women who had diabetes before pregnancy, or whose diabetes was undiagnosed before pregnancy; gestational diabetes that starts in the second half of pregnancy does not cause birth defects:

1- In early pregnancy, maternal diabetes can result in:

• Birth defects affect major organs such as the brain and heart.
• Increased rate of miscarriage.

2- During the 2nd and 3rd trimester:

• Maternal diabetes can lead to over – nutrition and excess growth of the baby.
• Having a large baby increases risks during labor and delivery.
• Large babies often require caesarean deliveries, and if he or she is delivered vaginally, they are at increased risk trauma to their shoulder.

3- After Birth:

• The baby may have low blood sugar (hypoglycemia) after birth. This is because the baby’s pancreas makes extra insulin in response to the mother’s high blood-sugar level. Shortly after birth, the baby may continue to make extra insulin even though high level of blood sugar is no longer present. After the pregnancy, the newborn blood-sugar level is measured regularly. Sometimes babies should be given an early feed of a sugar (glucose) solution through a drip (fed directly into a vein) to correct low blood sugar.
• It is more likely that the newborn baby will develop jaundice (yellowing of the skin and whites of the eyes). This is usually mild and disappears within 1-2 weeks, but some babies need light treatment (phototherapy), so the baby’s color should be checked and any jaundice reported to the doctor.
• There may be an increased risk of the baby developing type II diabetes or being overweight later in life.
• If the mother had diabetes before pregnancy that was not well controlled, there is an increased risk that the baby will be born with congenital problems, such as a heart defect. Sometimes infants can be born with respiratory distress syndrome, in which the baby has problems in breathing because his or her lungs do not mature normally. This usually clears up with time.
• There is also a slightly higher chance of stillbirth or death as a newborn, but if it is detected and the glucose level was managed. Death is rare.
• This increases the rate of admission to NICU.

4- Effects on the mother

• Gestational diabetes is not an immediate threat to the woman’s health. Most of those in whom blood sugar levels stay within the normal range, deliver their babies without complications. However, in some cases, it may lead to high blood pressure. Women who got gestational diabetes are more likely to develop gestational diabetes in next pregnancy, and developing type II diabetes later in his or her life.
• In almost every case, gestational diabetes disappears on its own after delivery, in which the blood-glucose level returns to normal about six weeks after childbirth. To be sure, every woman who had gestational diabetes should have a blood sugar test (a glucose tolerance test or fasting sugar) about 6-12 weeks after delivery, and then a diabetes check (such as HbA1c) every year for life, especially before planning another pregnancy.
• Women who have had gestational diabetes are about 7-10 times more likely to develop type II diabetes later in life, and up to half of them develop it within 5-10 years. However, they can reduce the risk of developing type II diabetes by maintaining an ideal body weight, following a healthy diet and exercising
• When and how does a woman with gestational diabetes give birth?
• **Delivery can occur before the 41st week of pregnancy if blood sugar levels are stable.
• **We may need to deliver the baby between the 37th and 39th weeks if blood sugar levels are not stable.
• **Delivery may be vaginal or cesarean, depending on the individual case.

Blood sugar readings should be monitored during Delivery to prevent severe hypoglycemia in the fetus after birth.

How should a baby be cared for after birth?

• Regularly monitor the newborn’s blood sugar levels.
• Breastfeeding is safe and should occur every 2-3 hours to prevent hypoglycemia in the newborn.

Dr Najeeb Layyous F.R.C.O.G

Consultant Obstetrician, Gynecologist and Infertility Specialist